Membership Application Membership Application If you are human, leave this field blank. Department sponsor: * Full Name: * Social Security Number: * Gender: * Male Female Date of Birth: * Marital Status: Married Single Separated Divorced Telephone Number: * Physical Address: * Email Address: * Place of Employment: * Supervisor: * Position/Occupation: * In case of emergency, please notify (name, address, and phone number): * Do you have any physical or mental limitations? * Do you have a valid drivers license? * Yes No If yes, please provide number and expiration date: Have you ever been convicted of a misdemeanor? * Yes No If yes, please indicate the charge(s), date, city/state, and disposition: Have you ever been convicted of a felony? * Yes No If yes, please indicate the charge(s), date, city/state, and disposition: Have you ever been dismissed, asked to resign, or had any disciplinary action taken against you from any employment or position you have held (paid or volunteer)? * Yes No If yes, please provide the reason and an explanation: Have you ever applied or been a member of another volunteer or career fire or EMS department? * Yes No If yes, please indicate the department, date, and disposition of application: Please list all fire certifications currently held: Please list all EMS certifications currently held: Please disclose any other information that you feel the Membership Committee should be aware of: Please provide three references, with name, telephone number, email address, and mailing address: * My typed name below indicates an electronic signature. By signing, I hereby affirm that all of the information contained in this application is true, correct, and complete to the best of my knowledge. I also understand that providing false or misleading information will automatically void my eligibility for membership to the Chuckatuck Volunteer Fire Department. I understand that all equipment issued to members retains the property of the department. At anytime, the Equipment Officer of the department has the right to inspect or repossess any or all equipment that is issued. All members are responsible for the care and upkeep of the equipment issued to them. I further understand that I give permission to the Chuckatuck Volunteer Fire Department and our insurance company to pull and discuss my current DMV record and criminal record. I acknowledge that I must submit to a fingerprinted background check as required by the Virginia Office of EMS. Submit
